artículo

1. Medical Education
A European consensus on learning objectives for a core communication
curriculum in health care professions
Cadja Bachmann a,
*, Henry Abramovitch b
, Carmen Gabriela Barbu c
, Afonso Miguel Cavaco d,e
,
Rosario Dago Elorza f
, Rainer Haak g
, Elizabete Loureiro h
, Anna Ratajska i
, Jonathan Silverman j
,
Sandra Winterburn k
, Marcy Rosenbaum l
a
Department of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
b
Department of Medical Education, Sackler School of Medicine, Tel Aviv University, Israel
c
Department of Endocrinology, Elias Hospital, Carol Davila University Bucharest, Romania
d
Department of Social Pharmacy, Faculty of Pharmacy, University of Lisbon, Portugal
e
Department of Social Pharmacy, School of Pharmacy, University of Oslo, Norway
f
Primary Care Paediatrician, Madrid, Spain
g
Department of Cariology, Endodontics and Periodontology, University of Leipzig, Germany
h
Center for Medical Education, Faculty of Medicine, University of Porto, Portugal
i
Institute of Psychology, Kazimierz Wielki University Bydgoszcz, Poland
j
School of Clinical Medicine, University of Cambridge, UK
k
School of Nursing Sciences, University of East Anglia, Norwich, UK
l
Department of Family Medicine, University of Iowa Carver College of Medicine, Iowa City, USA
1. Introduction
Communication in health care has become a major topic in the
past few decades [1,2] and the impact of providers’ communication
competencies on patients’ clinical outcomes and communication
in medical teams have been a significant area of focus [3–6].
Research has consistently demonstrated clear links between
effective clinical communication and patient satisfaction, adher-
ence, recall, symptom relief and physiological outcomes of care [7–
11]. Although comprehensive approaches to teaching communi-
cation skills within medical education and a number of consensus
statements, frameworks and models already exist [12–21], most of
these have been focused on training single provider groups,
namely physicians.
Outside of medical education, only a few examples exist of
published systematic approaches to communication skills training
Patient Education and Counseling 93 (2013) 18–26
A R T I C L E I N F O
Article history:
Received 25 April 2012
Received in revised form 14 October 2012
Accepted 27 October 2012
Keywords:
European consensus
Core communication curriculum for health
care professions
Objectives for undergraduate education
A B S T R A C T
Objective: To develop learning objectives for a core communication curriculum for all health care
professions and to survey the acceptability and suitability of the curriculum for undergraduate European
health care education.
Methods: Learning objectives for a Health Professions Core Communication Curriculum (HPCCC) in
undergraduate education were developed based on international literature and expert knowledge by an
international group of communication experts representing different health care professions. A Delphi
process technique was used to gather feedback and to provide a consensus from various health care
disciplines within Europe.
Results: 121 communication experts from 15 professional fields and 16 European countries participated
in the consensus process. The overall acceptance of the core communication curriculum was high. 61
core communication objectives were rated on a five-point scale and found to be relevant for
undergraduate education in health care professions. A thematic analysis revealed the benefits of the
HPCCC.
Conclusions and practice implications: Based on a broad European expert consensus, the Health
Professions Core Communication Curriculum can be used as a guide for teaching communication inter-
and multi-professionally in undergraduate education in health care. It can serve for curriculum
development and support the goals of the Bologna process.
ß 2012 Elsevier Ireland Ltd. All rights reserved.
* Corresponding author at: Department of Primary Medical Care, Center of
Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Martinistr.
52, D-20246 Hamburg, Germany. Tel.: +49 40 7410 54200; fax: +49 40 7410 53681.
E-mail address: c.bachmann@uke.uni-hamburg.de (C. Bachmann).
Contents lists available at SciVerse ScienceDirect
Patient Education and Counseling
journal homepage: www.elsevier.com/locate/pateducou
0738-3991/$ – see front matter ß 2012 Elsevier Ireland Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.pec.2012.10.016

2. in other healthcare professional groups [22–25]. Communication
training in undergraduate education within non-medical health-
care professions is less well developed and has been hampered by
the lack of available resources for both research and training. The
provision of common learning objectives in communication for
health care professionals across disciplines is still rare [26,27]
despite considerable overlap in the core communication process
skills used in different professional groups. This is an issue both for
inter-professional approaches to education (more than one
provider group learning together) and multi-professional
approaches (having a common educational approach across
different provider groups taught separately from each other). This
is despite the importance of the Bologna declaration [28] for many
health care professions within Europe. The Bologna process aims to
restructure European higher education ensuring comparability
and compatibility of academic education and degrees, and to
provide more flexibility among different academic fields, encour-
aging more inter-professionality in European education. A core
communication curriculum applicable in all health care profes-
sions throughout Europe, which defines common inter-profes-
sional objectives in communication for undergraduate/pre-
registration teaching and is based on a broad European consensus,
can be a first step to improve the current situation.
To develop a core communication curriculum for all health care
professions, expertise from many European countries and different
health care professions is needed. The European Association for
Communication in Health Care (EACH) has established the
subcommittee ‘‘tEACH’’ to support the development of communi-
cation teaching throughout Europe. In 2008, the committee
established a work-group with 46 experts from 18 European
countries. All participants are involved in curricular development,
teaching, assessing communication skills and/or train-the-trainers
programs. The different health care professions represented in the
group include medicine, midwifery, nursing, pharmacy, psycholo-
gy, dentistry and physiotherapy. The ‘‘core communication
curriculum subgroup’’ of tEACH, has taken the challenge to
develop and achieve consensus on a Health Professions Core
Communication Curriculum (HPCCC) to be used for undergraduate
education in Europe.
2. Methods
To develop the HPCCC and to achieve a European consensus, a
systematic academic approach and the Delphi technique were
used [29–31]. The process of the curriculum development was split
in 4 phases within the process: (1) development of a first draft by
10 tEACH subgroup experts on basis of literature [12–20,32–57],
and expert knowledge within the subgroup; (2) first Delphi round
with 24 communication experts from 14 European countries
within tEACH in order to give recommendations for revising the
first draft; (3) second Delphi round with 27 tEACH experts from 15
countries to test the revised draft and make suggestions for
improvement (4) a final Delphi round for the European consensus
with 84 European communication experts outside of tEACH from
16 countries coming from 15 professional health care fields rating
the draft.
Curriculum development and the Delphi process in detail
(Fig. 1):
1. Expert information exchange and literature review:
Development of the first draft was achieved through review
of existing literature and extensive discussion by 10 tEACH
members from 8 countries representing 7 different health care
professions. Our methodological approach was to develop initial
objectives drawing on existing consensus statements, frame-
works and guidelines. These statements are based on evidence
and expert knowledge and they have a broad acceptance among
communication professionals. When we could not find consen-
sus statements in non-medical professions we then included
articles reflecting the teaching of communication skills and
curriculum development for various professional groups in
various languages and countries in order not to miss relevant
aspects. These articles were published in English, German,
Romanian, Spanish, Polish and Portuguese [31–56].
The consensus statements and relevant frameworks were
analyzed under three major categories: 1) ‘key communication
tasks’ focusing on relationship building and information
exchange with patients; 2) ‘recommended skills’ focusing on
observable skills and communication techniques; 3) ‘special
communication tasks’ focusing on challenging situations and
team communication (Table 1).
Based on this analysis, we decided to use the Basel Consensus
Statement [16] as the basis for the first draft of the HPCCC. There
were several reasons for using the Basel consensus. These
include that among the available taxonomies, the Basel
Consensus was one of the most comprehensive in inclusion
and detailed description of objectives and that objectives were
defined according to Bloom’s taxonomy using a skills based
approach. Because the Basel Consensus focuses on social as well
as communication competencies, we removed those objectives
highly related to social competencies as they were outside the
purpose of HPCCC. Remaining objectives were then modified to
cover additional aspects revealed in the literature review and to
make the objectives more suitable for inter- and multi-
professional needs. The first draft contained 100 objectives to
be achieved by the end of undergraduate/pre-registration
education in health care professions.
2. Delphi process
First Delphi round: The first draft was inter-professionally
reviewed by 24 communication experts within tEACH in order
to assess inter- and multi-professional relevance, importance
and applicability of the different objectives. This first Delphi
round within the tEACH group led to a revision of the first draft.
Aspects deemed unimportant in that they had a lower than 60%
acceptance rate were eliminated. Ambiguous aspects were
reworded and new aspects incorporated (i.e. inter-cultural or
gender communication). The emerging second version resulted
in 66 learning objectives.
Second Delphi round: All members of tEACH apart from the
‘core curriculum group’ (n = 36) were invited to rank the 66
objectives in the second draft using a ranking from 1 to 5 (1:
most important, 2: very important, 3: important, 4: rather
unimportant and 5: unimportant). 27 tEACH members
responded leading to the exclusion of 5 objectives resulting
in a final draft containing 61 learning objectives covering three
main topics: 1) communication with patients (34 objectives); 2)
intra- and interpersonal communication (12 objectives) and 3)
communication in health care teams (15 objectives). Learning
objectives were grouped under subheadings: where learning
objectives could fit under more than one subheading, they were
allocated to a single place within the document, with the
intention that future users of the document could be flexible
about groupings. Delineation of core communication objectives
that could apply to any clinical interaction were followed by
more detailed specific objectives, applicable depending on
different contexts and tasks.
Third Delphi round: The final draft was sent out to European
communication experts outside of tEACH who had experience in
teaching, assessing and/or curricular development in commu-
nication for health professionals. tEACH members contacted up
to ten communication experts from different health care
C. Bachmann et al. / Patient Education and Counseling 93 (2013) 18–26 19

3. professions in their countries with the request that they rank the
61 objectives with regard to importance on a 5-point-Likert-
scale (1: most important, 2: very important, 3: important, 4:
rather unimportant and 5: unimportant). The experts were also
asked to comment on the HPCCC as a whole and the usability of
the curriculum within their own professional field. In addition,
experts described their experience in teaching, assessing and/or
developing curricula in communication in their professional
field.
3. Data analysis
Data from the final Delphi round was entered into an SPSS-
database. Analysis was undertaken by nine members of the
‘tEACH core communication curriculum subgroup’. Quantitative
analysis is based on descriptive analysis, parametric and non-
parametric tests, such as Mann–Whitney U. Impact of impor-
tance on each objective was measured in means and medians,
the acceptance of each objective was calculated on basis of the
percentage of consensus experts who rated the objective as
‘‘most important’’, ‘‘very important’’ or ‘‘important’’. Qualitative
analysis using a thematic approach identified the salient themes
in participants’ comments regarding the overall HPCCC and
applicability to their own profession. Comments in each
category were reviewed by four members of the ‘core
communication curriculum subgroup’ to identify initial themes
Fig. 1. Development of core curriculum and Delphi process.
C. Bachmann et al. / Patient Education and Counseling 93 (2013) 18–2620

4. that made up a preliminary coding scheme. Coders then
compared their coding to achieve consensus on the coding
scheme and then codes were reviewed to ensure that all
comments could be categorized by these main themes.
3. Results
3.1. Participants of the consensus process
In total, 121 communication experts were included in the
consensus process: 10 from the core curriculum group of tEACH,
27 members of tEACH not in the core curriculum subgroup
(Delphi round 1 and 2), and 84 multi-professional communica-
tion experts outside of tEACH from 16 European countries
representing Azerbaijan, Belgium, Denmark, Germany, Greece,
Ireland, Israel, Italy, the Netherlands, Norway, Poland, Portugal,
Romania, Spain, Switzerland and the United Kingdom (Delphi
round 3). Participants in this final Delphi round (n = 84) came
from 15 professional fields including medicine, psychology,
dentistry, nursing, pharmacy, midwifery, speech- and language-
therapy, osteopathy, physiotherapy, health communication,
education, social work, sociology, specialists in cultural compe-
tence and Simulated Patient programs. 47 participants came
from non-medical and 37 from medical professions (Fig. 2).
60.7% (n = 51) of the participants were female. The average
amount of experience participants had in teaching and/or
assessing communication skills was 12.38 years. While one
third worked in either undergraduate or postgraduate education,
two thirds worked with learners in both. About one fourth
worked in more than one professional field (e.g. medicine and
nursing). Presentation of results focuses on responses from 84
participants in Delphi round 3.
3.2. Quantitative analysis
The acceptance of the 61 core communication curriculum
objectives was very high (Table 2). Quantitative analysis
revealed that on average all communication objectives had a
high relevance for education in all health care professions with a
range from 84 to 100%. 11 objectives had an acceptance of 100%,
which means all experts had rated the objectives as most
important, very important or important. 45 objectives had an
acceptance of 90–99% and 5 objectives had an acceptance of 84–
89% indicating that some participants rated these objectives as
somewhat unimportant or unimportant. Means, standard
Fig. 2. Professions of participants.
Table 1
Comparison of consensus statements/frameworks.
Toronto Kalamazoo UK Basel CanMEDS MAAS
Key Tasks
Build relationship, developing trust & rapport H H H H
Elicit information from the patient/Problems and concerns H H H H H H
Consider the patients perspective of the illness H H H H H H
Give relevant information and explanations H H H H H H
Develop shared plan of care H H (H) H H H
Closing the interview & setting up next meeting H H H
Recommended skills
Active listening H H H H H H
Empathy H H H H H
Responding to verbal/non verbal cues H H H H H
Attention to questioning style (open/closed, etc.) H H H H H
Summarizing H H H H
Explanation and planning H (H)
Structuring (H) (H) H H H
Reflection H H H
Clarification H H H H
Chunking information and checking understanding H H (H) H H
Adapting to language level H
Specific Tasks
Breaking bad news H H H H
Specific clinical contexts e.g. psychiatric disorders anxiety/depression/aggression H (H)
Cultural/social diversity H H H H
Handling emotions/difficult questions H H H H H
Dealing with uncertainty H H
Age specific i.e. children H H (H)
Sensitive issues e.g. sex, death and dying H H H H
Triadic consultations/emergency H H
Dealing with errors/mistakes H H
Team-/inter-professional communication, leadership H H
Communication impairment H
Media H
(H) = not explicitly mentioned or subsumed.
C. Bachmann et al. / Patient Education and Counseling 93 (2013) 18–26 21

5. Table 2
The Health Professions Core Communication Curriculum: objectives for undergraduate education in health care professions.
Meana
(SD) Acceptanceb
in %
A. Communication with patients
Core communication objectives:
The student. . .
1 Adapts own communication to the level of understanding and language of the patient, avoiding jargon. 1.41 (0.59) 100.0
2 Uses techniques to build up and maintain rapport and an empathetic relationship and ensures that the
patient feels attended and listened to.
1.45 (0.70) 100.0
3 Relates to the patient respectfully including ensuring confidentiality, privacy and autonomy and
recognizes the patient as a partner in shaping a relationship.
1.47 (0.69) 98.8
4 Elicits and explores the content of the patient’s bio-psycho-social history (e.g. gathers relevant
information, ensures understanding, relays information understandably, verbalizes emotional content).
1.53 (0.67) 100.0
5 Encourages the patient to express own ideas, concerns, expectations and feelings and accepts legitimacy of
patient’s views and feelings.
1.54 (0.74) 98.8
6 Gives information to the patient (oral, written, electronic and over the phone) in a timely, comprehensive
and meaningful manner.
1.54 (0.67) 100.0
7 Uses techniques of active listening (e.g. reflection, picking up patient’s cues, paraphrasing, summarizing,
verbal and non-verbal techniques).
1.57 (0.74) 98.8
8 Recognizes difficult situations and communication challenges (e.g. crying, strong emotional feelings,
interruptions, aggression, anger, anxiety, embarrassing or sensitive issues, cognitive impairment,
delivering bad news) and deals with them sensitively and constructively.
1.57 (0.70) 100.0
9 Shows awareness of the non-verbal communication of both the patient and the healthcare professional
(e.g. eye contact, gestures, facial expressions, posture) and responds to them appropriately.
1.60 (0.68) 100.0
10 Shapes a conversation from beginning to end with regard to structure (e.g. introduction, initiating the
conversation, gathering and giving information, planning, closing interview, setting up next meeting; time
management).
1.72 (0.82) 97.6
11 Uses different types of questions (e.g. open, closed and focused) according to the situation. 1.78 (0.78) 98.8
More detailed specific objectives, depending on context and situation:
Shaping of relationship: The student involves the patient in the interaction to establish a therapeutic relationship using a
patient-centered approach
12 Identifies patient expectations with respect to the role of health care professional. 1.81 (0.74) 100.0
13 Uses adequate strategies to solve conflicts (e.g. feedback on perception, impact, wishes). 2.12 (0.85) 95.2
Patient’s perspective and health beliefs: The student orients own communication in line with the actual needs and concerns
of the patient
14 Elicits the needs and capabilities of the patient (e.g. information, autonomy, truth and responsibility) and
adapts the plan/intervention to patient’s resources and strengths.
1.71 (0.79) 100.0
15 Considers somatic, mental, social, gender, cultural, ethical and spiritual elements in the care and
assessment of the patient and perceives divergences between own values and norms and the patient’s.
1.92 (0.83) 98.8
16 Responds to the patient’s health beliefs and theories of illness and contrasts and integrates these into own
theories of illness as a health care professional.
2.02 (0.89) 96.3
Information: The student effectively collects and communicates relevant information for reasoning and decision-
making
17 Finds out how much information the patient requires and gives the appropriate amount of information. 1.71 (0.71) 100.0
18 Provides information in a patient-centered way and shares it with the patient’s consent (e.g. colleagues,
family and others.)
1.81 (0.82) 97.6
19 Elicits and synthesizes information for patient care. 1.83 (0.73) 100.0
20 Inquires about the patient’s level of knowledge about the illness 1.87 (0.79) 98.8
21 Considers different elements of a patient history (history of the illness, history of the health care
professional–patient relationship, history of the patient).
2.10 (0.86) 95.1
22 Knows about the importance of supplementing verbal information with diagrams, models, written
information and instructions and applies the information appropriately.
2.18 (0.89) 94.0
23 Seeks out and synthesizes relevant information from other sources (e.g. patient’s family, caregivers and
other professionals), if necessary and available
2.19 (0.90) 94.0
Reasoning and decision-making: The student considers the extent to which individuals are involved and responsible in the
reasoning and decision-making process
24 Ascertains how much involvement and responsibility the patient is willing and able to take for decision-making. 1.77 (0.79) 97.6
25 Discusses with the patient the likely advantages, disadvantages and expected outcomes 1.80 (0.76) 100.0
26 Encourages active participation by the patient in decision-making and explains choices or rights to the
patient in a patient-centered manner.
1.82 (0.86) 96.3
27 Clarifies own role in decision-making process. 1.96 (0.98) 95.2
28 Discusses with patient the spectrum of possible consequences of a decision and explains to the patient the
likely consequences of not choosing diagnostic and therapeutic measures.
2.02 (1.01) 94.0
29 Inquires about the relevant psychological and social resources the patient has available for making a decision. 2.06 (1.03) 92.6
30 Offers the patient the option to include other people in the decision- making process and clarifies with the
patient how and when a decision must be made.
2.22 (1.08) 90.4
31 Discusses decisions with colleagues, patients and their relatives as appropriate and regularly reassesses
own decisions and revises them if necessary.
2.23 (0.98) 94.0
32 Identifies own opinion clearly to the patient if asked. 2.30 (1.10) 86.4
Uncertainty: The student respects uncertainty as an integral part of reasoning and decision-making
33 Talks openly to the patient about uncertainty and formulates ways of dealing with it. 2.11 (0.92) 95.1
34 Explains to the patient which information is needed to minimize uncertainty in the decision-making process. 2.22 (1.00) 91.4
B. Intra- and interpersonal communication (Professionalism and Reflection)
Communication and reflection with self and others: The student consistently develops and improves self-awareness,
self-reflection, self-care and reflects with others on own communication and behavior
1 Recognizes own emotions (e.g. insecurity, sympathy/antipathy, attraction) in relation to others (e.g.
patients, colleagues) and is able to work efficiently despite own emotional reactions when the situation
requires to do so (e.g. degree of suffering of the patient, demanding patient).
1.55 (0.82) 98.8
C. Bachmann et al. / Patient Education and Counseling 93 (2013) 18–2622

6. deviations and acceptance are listed in Table 2. Highest
relevance was found among objectives for core communication
skills with patients, followed by intra- and inter-professional
communication and communication in health care teams. 11
objectives reached a median of 1 (most important), 49 had a
median of 2 (very important) and one had a median of 3
(important). Some participants ranked single objectives as
unimportant but none of the learning objectives had a median
of 4 (rather unimportant) or 5 (unimportant).
For ‘communication with patients’ those perceived as most
important objectives included: adaptation to patient’s under-
standing and language, empathic relationship building and
maintenance, respect and partnership, exploration of the content
of the patient’s history, patients’ expectations, needs and feelings,
giving information, active listening and awareness to non-verbal
communication, sensitivity towards difficult situations and
communication challenges. Also self-reflective learning objectives
were scored as most important, such as recognition of own
emotions and effectiveness of communication and improved
clinical outcomes.
Non-parametric tests (Mann–Whitney U) were conducted to
ascertain statistical associations between main professional areas.
No statistical significance was found between the different
professions in how they rated the objectives.
3.3. Qualitative analysis
72 of the 84 participants responded to the question asking
them to comment on the HPCCC as a whole and these comments
helped to explain participants’ ratings. Overall, the comments were
very positive, describing the curriculum objectives as well
designed and comprehensive and the curriculum as a highly
relevant tool. Thematic analysis enabled the identification of three
broad categories: 1) importance of the document; 2) shortcomings
and demands; and 3) process of implementation, training and
assessment measures additional to the core curriculum.
Typical comments in regard to the importance of the objectives
stated that the core curriculum is ‘‘very important for the education
process of all health care providers’’ or ‘‘very applicable’’ or ‘‘includes
all relevant issues’’. The comments included phrases like:
Table 2 (Continued )
Meana
(SD) Acceptanceb
in %
2 Recognizes that effective communication with patients can foster patients’ satisfaction and improved clinical outcomes. 1.64 (0.81) 97.5
3 Describes and assesses own communication and behavior critically considering alternatives in both. 1.77 (0.82) 98.8
4 Identifies, reflects and communicates own strengths, weaknesses, limitations and assesses own wishes,
fears, goals, norms and values.
1.83 (0.80) 98.8
5 Assesses own stereotypes and social prejudices and is aware that own actions are influenced by personal
experience, the current situation, own knowledge and interests.
1.93 (0.91) 97.6
6 Reflects on own attitude towards work (e.g. cynicism, satisfaction). 2.05 (0.87) 95.1
7 Reflects and discusses ethical, inter-cultural and other challenges in own actions as a health care
professional (e.g. patient unable to give consent, health/illness concepts in different cultures, translators)
and discusses approaches for resolution.
2.12 (0.99) 91.5
8 Uses authority and influence responsibly. 2.15 (1.01) 88.9
9 Analyses and discusses conversational situations with others (metacommunication in e.g. peer reflection,
team conferences, Balint groups).
2.30 (1.04) 85.4
10 Knows about models of the health care professional–patient relationship (e.g. transference/counter
transference, reciprocity, inter-subjectivity, expectation/experience, potential imbalance of hierarchy).
2.48 (1.03) 84.1
Dealing with errors and uncertainty: The student addresses errors and respects uncertainty as an integral part of
reasoning and decision-making
11 Addresses own and others errors appropriately (e.g. refrains from personally allocating blame) in order to
seek for solutions and assistance and knows about basic principles in the development of errors (e.g.
neglecting information or patient’s needs, inadequate communication).
1.80 (0.85) 96.4
12 Addresses and deals with own uncertainty appropriate to own level of education. 1.91 (0.84) 97.5
C. Communication in health care teams (professional communication)
Teamwork and professional communication: The student shows ability to communicate effectively in multi-professional teams
1 Perceives and respects individuality, subjective perception, different points of view of team members and
the expertise of the different health care professionals.
1.83 (0.94) 95.1
2 Contributes to a positive working atmosphere (e.g. supports and integrates team members, mentions the
positive side of unpleasant aspects, values team-success).
1.90 (0.90) 96.3
3 Uses feedback rules (e.g. first-person-statements) and gives feedback to team-members appropriately. 1.90 (0.91) 98.8
4 Is able to solve conflicts and enables a constructive negotiation in a healthcare team. 1.96 (0.92) 93.8
5 Takes on, clarifies and reflects on own role and responsibilities in the team (e.g. team vs. team-player,
leader) and identifies the role of own profession in an inter-professional team.
2.04 (0.92) 95.1
6 Specifies and appreciates own potential with regard to the team and is willing and able to work with others. 2.01 (0.90) 93.9
7 Understands the principles of team dynamics and how factors both support and inhibit teamwork in practice. 2.29 (0.88) 95.1
8 Identifies own interests and distinguishes these from the team goals. 2.26 (1.02) 90.2
9 Reflects on the impact of own opinion on others and takes this into account. 2.32 (1.00) 88.9
Leadership: The student shows basic competencies in leadership skills
10 Gives clear instructions. 1.87 (0.91) 94.0
11 Ensures that all relevant information is available. 2.04 (0.87) 93.9
12 Facilitates the formation of opinions in the group and encourages and rewards team members to voice
differing opinions.
2.20 (0.91) 92.7
Professional communication and management: The student uses effective and efficient communication and management strategies
13 Maintains clear, appropriate records (written or electronic) of clinical encounters and plans. 1.75 (0.84) 98.8
14 Presents expert knowledge effectively (e.g. presenting a patient and clinical details to others, speaking in
front of a group, presenting scientific data).
1.82 (0.83) 98.8
15 Identifies and is knowledgeable of how to refer to people/institutions/agencies that can help to solve
problems appropriate to the situation.
1.93 (0.87) 98.8
a
Ranking of objectives: 1 = most important; 2 = very important; 3 = important; 4 = rather unimportant; 5 = unimportant.
b
Definition of acceptance: % of participants who rated objectives as most important, very important or important (e.g. 100% acceptance means that all participants rated
the objective in one of the three categories).
C. Bachmann et al. / Patient Education and Counseling 93 (2013) 18–26 23

7. ‘‘Wonderful, it is exactly what we would like to teach our students’’,
‘‘excellent and comprehensive’’, ‘‘a rich and systematic tool’’ and ‘‘it is
a good balance of the different functions of communication acts’’. Most
experts appreciated the detailed description of learning objectives,
the innovative approach, the importance of defining communica-
tion goals for all health care professions and the benefit of having a
structured and comprehensive tool that covers all important
aspects of communication.
Some individual participants made suggestions for additions to
the HPCCC such as motivational interviewing or working with
language minorities or a more detailed specification of target
groups like communication with children, elderly, psychiatric
patients, and speech disabilities.
Some respondents (n = 9) were concerned about implementa-
tion issues related to the curriculum, specifically the length of the
curriculum or ambitious objectives and suggested a need to
prioritize the list, which is now available. Most important learning
objectives can be extracted from the HPCCC by using the ranking
scores of means or ‘‘acceptance of objectives’’ (Table 2), but the
great majority felt that e.g. ‘‘it is hard to see how any of it is
unimportant’’. Some participants (n = 8) noted that having addi-
tional information about implementation of the curriculum
including such aspects as amount and intensity of training, time
constraints, and assessment would be helpful.
Participants were also asked to indicate, if they could use the
core curriculum for undergraduate education in their own
professional field. 97.2% of the participants who answered the
question (n = 71), responded positively stating they could either
use it as a whole (n = 60) or with modification in parts (n = 9). Some
participants (n = 8) expressed that the curriculum was very similar
to their own existing program. Of those who did not answer the
question about applicability in the own profession (n = 13), no one
gave a negative statement on the curriculum as a whole and no
statistically relevant difference was found between the two groups
– those who answered the applicability question and those who
did not – with regard to acceptance of learning objectives.
4. Discussion and conclusion
4.1. Discussion
Effective communication should be a major goal for all health
care education. Our approach to developing objectives for a
comprehensive inter- and multi-professional communication
curriculum was based on the assumption that in communication
with patients, their relatives and in health care teams, core skills
are common to all health professionals. Effective communication
should be the same whether done by a nurse, pharmacist, dentist,
doctor or other specialist. Therefore, common communication
skills applicable in all health care professions should be taught in
undergraduate or pre-registration education. Consensus state-
ments, frameworks, model curricula and relevant seminal papers
from different countries and professions exist, but the current
work is the first inter- and multi-professional, European consensus
approach to be carried out.
The inter-professional information exchange between Europe-
an communication experts from 16 different countries within
tEACH, along with the analysis of the literature, revealed
deficiencies in the curricular development of communication
skills training for the different health care professions across
Europe. Some health care professions lack communication
curricula completely with only a few non-medical professions
having systematically implemented any communication curricula
into their undergraduate education. Whilst medical schools have
led the way in several European countries, some countries and
many health care professions have just or not yet started to
implement communication into their undergraduate education.
The state of development and implementation within the different
European countries and health care professions is heterogeneous
indicating a need for the development of an inter- and multi-
professional European solution. This would also contribute to
addressing demands of the Bologna Initiative for comparable
curricula in European higher education.
4.1.1. Main results
An international and multi-professional expert group devel-
oped a core communication curriculum to be applicable in
undergraduate education in all health care professions. The Health
Professionals Core Communication Curriculum aims to serve as a
guideline for objectives to be taught in undergraduate/pre-
registration education. The learning objectives focus not only on
‘communication with patients’ but also on ‘communication in
inter- and multi-professional teams’ as well as ‘professionalism
and reflection’.
The HPCCC provides 61 learning objectives for undergraduate
education to be accomplished by the end of the various health care
degree programs. The overall acceptance by communication
experts on these objectives was very high. Comments by
participants in the consensus process indicated the need for and
importance of a tool like the HPCCC and appreciation for its
comprehensiveness. The ranking of importance of each subject as
measured by means and ‘‘acceptance of objective’’ gives an insight
into the relevance of the different skills and most important
objectives can now be educed from the HPCCC. The request from
some consensus participants to highlight most important skills is
therefore given. As the taxonomy of the objectives was adapted to
the Basel Consensus Statement [16] with a detailed, skills-based
description of objectives, the HPCCC aims to use the objectives for
teaching and it could also be used for assessment.
4.1.2. Findings in relation to relevant literature
The HPCCC builds on and extends existing consensus state-
ments available in the literature and offers a new inter- and multi-
professional approach to teaching communication in health care.
While several consensus statements on communication skills
teaching for medical education exist [13–18], the majority of these
were based on consensus of a comparatively smaller number with
21–33 expert participants in the consensus process. The Basel
Consensus Statement [16] is based on the broad acceptance of
more than 100 communication experts and due to the skills-based
taxonomy it was a comprehensive tool for the development of the
HPCCC. Unfortunately, we were unable to find any communication
consensus statements for non-medical professions in our literature
search in various languages and countries, which was congruent
with our inter-professional expert information exchange indicat-
ing that comprehensive communication skills models and training
has not been well developed outside of medicine. In addition to
these findings, the literature does not contain any blueprint for an
inter- or multi-professional approach to delineating communica-
tion skills. Therefore, the HPCCC adds to this body of literature
through its emphasis on inter- and multi-professional objectives
and can be a beneficial tool for many health care professions.
4.1.3. Limitations and implications for future directions
The HPCCC has been evaluated focusing on inter- and multi-
professional application of the learning objectives in multiple
Delphi process steps by 121 multi-professional and international
communication experts. The participants of the final Delphi
process were personally recruited by tEACH members, who knew
that these experts had experience in teaching communication in
their own professional field and expertise to evaluate the relevance
of the different learning objectives. Many experts in the final
C. Bachmann et al. / Patient Education and Counseling 93 (2013) 18–2624

8. Delphi round came from medical education, revealing the high
expertise in this professional field and relating to the current state
of curriculum development in many European countries, whilst it
was challenging to find communication experts in other profes-
sions. More expertise from non-medical professions might have
enhanced the process. Still, nearly 60% of our experts came from
non-medical education and our results showed no difference
related to professional area in regard to acceptance of the
objectives. We therefore presume that the HPCCC can serve as a
guideline for curricular development in different health care
professions and between them. Thus, the curriculum can also lead
the way to enforce the goals of the Bologna process.
The HPCCC does not yet provide a direction for when and how to
teach or assess the different objectives as some communication
experts asked for in their comments, and discussion of these issues
is beyond the scope of the current paper. Following the Kern model
of curriculum development [58], the next step for the tEACH group
will be to complement the objectives with appropriate teaching
and assessment tools as well as suggestions for qualified train-the-
trainer programs and evaluation systems.
The communication experts came from various professional
fields, countries and cultural backgrounds. We were unable to
undertake elaborated subgroup analyses with regard to coun-
tries or cultures as some of the subgroups were too small. While
we found some higher standard deviations on some objectives,
we could not find clear patterns based on professional field or
rater country of origin to explain these differences. Future
research on the HPCCC, using larger and more representative
samples, could examine how professional background and/or
country of origin and cultural differences influence levels of
acceptance of specific objectives. In addition, perspectives of
patients and students on the relative importance of HPCCC
objectives could be explored.
The HPCCC, based on a broad multi-professional consensus
process, provides common core communication learning objec-
tives for undergraduate education in health care professions. Due
to the high acceptance among European communication experts
from various health care disciplines the HPCCC can be used inter-
and multi-professionally by applying objectives within but also
amongst the various health care professions. Still, the HPCCC
cannot be static but must reflect changes within the health care
culture and the broader society as a whole. Therefore, what we
have proposed is a dynamic, flexible framework, which can be
expanded or reduced. Means and ‘‘acceptance’’ point to those
objectives which were considered most important to include in
communication skills curriculum and also identify potentially new
objectives that could be added to already existing curricula. We
decided to focus the HPCCC on undergraduate education applicable
in all health care professions and European countries but we
presume that the HPCCC can and will be adapted to the specific
needs of individual professions and reflect the diverse and
changing communication challenges of health professionals. Areas
for consideration in the future could include dealing with
electronic media information, goal setting and monitoring,
motivational interviewing, and communicating with specific
target groups or translators. Further refinement of the objectives
might focus on the salience and importance of the expert
consensus as seen from the patient’s perspective. Future investi-
gation will be needed to give insight into implementation and
adoption processes.
4.2. Conclusion
A core communication curriculum for undergraduate or pre-
registration education in health care professions was developed by
an expert group and consented in a European Delphi process with
121 multi-professional communication experts. 61 learning
objectives were defined in a detailed, skills-based taxonomy and
a ranking score reveals the relevance of each objective. The
communication curriculum achieved high acceptance among
European communication experts and can now be used as an
inter- and multi-professional guideline for curriculum develop-
ment within and among the different European countries and
health care professions and it can give support to enhance the
Bologna process.
4.3. Practice implications
The European consensus on objectives for a Health Professions
Core Communication Curriculum delivers a framework for health
care professions and institutions that plan to implement commu-
nication into their curricula or that want to restructure their
teaching or assessment in communication. The HPCCC can be used
inter- and multi-professionally. As non-medical consensus state-
ments do not exist and many professions and countries have not or
just started to integrate communication into health care education,
the HPCCC can also give legitimacy and support for curriculum
development processes in the various health care disciplines. The
core curriculum covers elements that should be part of under-
graduate communication curricula in health care but the HPCCC is
meant as a flexible framework and can be implemented into
curricula as a whole or in parts. It can be used as a guide for
teaching communication skills and for developing assessments.
The decision regarding the extent to which the different objectives
are implemented, taught and assessed should be left to the
discretion of the different institutions as teaching loads, staff
capacities and logistics as well as assessment facilities have to be
adapted individually at each institution. With growing experience
on implementation processes of the HPCCC, research and re-
evaluation of the core communication curriculum will need to
follow in future.
Conflict of interests
The authors have no conflicts of interest.
Acknowledgements
We would like to take this opportunity to thank all communi-
cation professionals who gave their support by participating in the
consensus process. Their comments and beneficial suggestions
have helped us to continuously improve the HPCCC. Unfortunately,
due to the large number of participants, we were unable to list all
experts by name as we had originally intended.
References
[1] Parrott R. Emphasizing ‘‘communication’’ in health communication. J Commun
2004;54:751–87.
[2] Rimal RN, Lapinski MK. Why health communication is important in public
health. Bull World Health Organ 2009;87:247.
[3] Tamblyn R, Abrahamowicz M, Dauphinee D, Wenghofer E, Jacques A, Klass D,
et al. Physician scores on a national clinical skills examination as predictors of
complaints to medical regulatory authorities. J Amer Med Assoc
2007;298:993–1001.
[4] Thompson DA, Cowan J, Holzmueller C, Wu AW, Bass E, Pronovost P. Planning
and implementing a systems-based patient safety curriculum in medical
education. Am J Med Qual 2008;23:271–8.
[5] Coulter A, Jenkinson C. European patients’ views on the responsiveness of
health systems and healthcare providers. Eur J Public Health 2005;15:355–60.
[6] Joint Commission on Accreditation of Healthcare Organizations. The Joint
Commission guide to improving staff communication. Oakbrook Terrace, IL:
Joint Commission Resources; 2005.
[7] Shilling V, Jenkins V, Fallowfield L. Factors affecting patient and clinician
satisfaction with the clinical consultation: can communication skills training
for clinicians improve satisfaction? Psychooncology 2003;12:599–611.
C. Bachmann et al. / Patient Education and Counseling 93 (2013) 18–26 25

9. [8] Jansen J, van Weert JCM, de Groot J, van Dulmen S, Heeren TJ, Bensing JM.
Emotional and informational patient cues: the impact of nurses’ responses on
recall. Patient Educ Couns 2010;79:218–24.
[9] Zolnierek KB, DiMatteo RM. Physician communication and patient adherence
to treatment: a meta-analysis. Med Care 2009;47:826–34.
[10] Joosten EAG, DeFuentes-Merillas L, de Weert GH, Sensky T, van der Staak CPF,
de Jong CAJ. Systematic review of the effects of shared decision-making on
patient satisfaction, treatment adherence and health status. Psychother Psy-
chosom 2008;77:219–26.
[11] Di Blasi Z, Harkness E, Ernst E, Georgiou A, Kleijnen J. Influence of context
effects on health outcomes: a systematic review. Lancet 2001;357:757–62.
[12] Silverman J, Kurtz SM, Draper J. Skills for communicating with patients, 2nd
ed., Oxford: Oxford Radcliffe; 2005.
[13] Simpson M, Buckman R, Stewart M, Maguire P, Lipkin M, Novack D, et al.
Doctor-patient communication: the Toronto consensus statement. Brit Med J
1991;303:1385–7 [Review].
[14] Makoul G. Essential elements of communication in medical encounters: the
Kalamazoo consensus statement. Acad Med 2001;76:390–3 [Review].
[15] Von Fragstein M, Silverman J, Cushing A, Quilligan S, Salisbury H, Wiskin C. UK
Council for Clinical Communication Skills Teaching in Undergraduate Medical
Education. UK consensus statement on the content of communication curric-
ula in undergraduate medical education. Med Educ 2008;42:1100–7.
[16] Kiessling C, Dieterich A, Fabry G, Holzer H, Langewitz W, Mullinghaus M, et al.
Communication and social competency in medical education in German
speaking countries: the Basel consensus statement. Results of a Delphi Study.
Patient Educ Couns 2010;81:259–66.
[17] Frank JR, editor. The CanMEDS physician competency framework. Better
standards. Better physicians. Better care. Ottawa: The Royal College of Phy-
sicians and Surgeons of Canada; 2005.
[18] Makoul G, Schofield T. Communication teaching and assessment in medical
education: an international consensus statement. Netherlands Institute of
Primary Health Care. Patient Educ Couns 1999;37:191–5.
[19] Aspegren K. BEME guide no. 2: teaching and learning communication skills in
medicine—a review with quality grading of articles. Med Teach 1999;21:563–70.
[20] Maguire P, Piceathly C. Key communication skills and how to acquire them.
Brit Med J 2002;325:697–700. 28.
[21] de Haes H, Bensing J. Endpoints in medical communication research, proposing
a framework of functions and outcomes. Patient Educ Couns 2009;74:287–94.
[22] Chant S, Randle J, Russell G, Webb C. Communication skills training in
healthcare: a review of the literature. Nurse Educ Today 2002;22:189–202.
[23] Fellowes D, Wilkinson S, Moore P. Communication skills training for health
care professionals working with cancer patients, their families and/or carers.
The Cochrane Database of Systematic Reviews 2004;2.
[24] Krijver IPM, Kerkstra A, Bensing JM, Van de Wiel HBM. Nurse–patient commu-
nication in cancer care: a review of the literature. Cancer Nurs 2000;23:20–31.
[25] Ajjawi R, Higgs J. Core components of communication of clinical reasoning: a
qualitative study with experienced Australian physiotherapists. Adv Health
Sci Educ Theory Pract 2012;17:107–19.
[26] Holt J, Coates C, Cotterill D, Eastburn S, Laxton J, Mistry H, et al. Identifying
common competences in health and social care: an example of multi-institu-
tional and inter-professional working. Nurse Educ Today 2010;30:264–70.
[27] Tucker K, Wakefield A, Boggis C, Lawson M, Roberts T, Gooch J. Learning
together: clinical skills teaching for medical and nursing students. Med Educ
2003;37:630–7.
[28] The Bologna Declaration on the European space for higher education: an
explanation by the Confederation of EU Rectors’ Conferences and the Associ-
ation of European Universities (CRE), http://ec.europa.eu/education/policies/
educ/bologna/bologna.pdf.
[29] Brown. Delphi Process: A Methodology Used for the Elicitation of Opinions of
Experts. http://www.rand.org/pubs/papers/2006/P3925.pdf; 1968.
[30] De Villiers MR, de Villiers PJT, Kent AP. The Delphi technique in health sciences
education research. Med Teach 2005;27:639–43.
[31] Fink A, Kosecoff J, Chassin M, Brook RH. Consensus methods: characteristics
and guidelines for use. Am J Public Health 1984;74:979–83.
[32] van Thiel J, Ram P, van Dalen J. MAAS-Global 2000. Netherlands: Maastricht
University; 2000, http://www.hag.unimaas.nl/maas-global_2000/GB/MAAS-
Global-2000-EN.pdf.
[33] Bachmann C, Ho¨lzer H, Dieterich A, Fabry G, Langewitz W, Lauber H, et al. [A
longitudinal Bologna-compatible model curriculum ‘‘communication and
social competencies’’: results of an interdisciplinary workshop of German-
speaking medical schools]. GMS Z Med Ausbild 2009;26:Doc38 [published in
German].
[34] Kuhlike K, Hilgers J, Sto¨rmann S, Hornung T, Dudziak J, Weinmann P, et al. [A
core curriculum for medical education in Germany: a proposal of German
medical students]. GMS Z Med Ausbild 2006;23:Doc 58 [published in Ger-
man].
[35] Haak R, Rosenbohm J, Koerfer A, Obliers R, Wicht MJ. The effect of undergrad-
uate education in communication skills: a randomised controlled clinical trial.
Eur J Dent Educ 2008;12:213–8.
[36] Sondell K, So¨derfeldt B, Palmqvist S. Underlying dimensions of verbal com-
munication between dentists and patients in prosthetic dentistry. Patient
Educ Couns 2003;50:157–65.
[37] Rossi PS, Batista NA. [The teaching of communication skills in medical schools
– an approach]. Interface – Comunic., Sau´ de, Educ. 2006;10(19):93–102.
[published in Portuguese].
[38] Nunes J. [Communication in the clinical context]. Bayer Health CARE, 2007,
Lisbon, Portugal [published in Portuguese].
[39] Carvalho IP, Ribeiro-Silva R, Pais VG, Figueiredo-Braga M, Castro-Vale I, Teles
A, Almeida SS, Mota-Cardoso R. [Teaching doctor-patient communication – a
proposal in practice]. Acta Med Port. 2010;23(3):527–32. [published in Por-
tuguese].
[40] Loureiro E, Severo M, Bettencourt P, Ferreira MA. Third year medical students
perceptions towards learning communication Skills: implications for medical
education. Patient Educ Couns 2011;85:265–71.
[41] Chant S, Jenkinson T, Randle J, Russell G. Communication skills: some pro-
blems in nursing education and practice. J Clin Nurs 2002;11:12–21.
[42] Parry R. Are interventions to enhance communication performance in allied
health professionals effective, and how should they be delivered? Direct and
indirect evidence. Patient Educ Couns 2008;73:186–95.
[43] Wilkinson S, Perry R, Blanchard K, Linsell L. Effectiveness of a three-day
communication skills course in changing nurses’ communication skills with
cancer/palliative care patients: a randomised controlled trial. Palliat Med
2008;22:365–75.
[44] Fica S, Minea L. [Communication and behavior guidelines in the medical
personnel–patient relationship]. Bucharest, Romania: ‘Carol Davila’ University
Publishing House; 2008.
[45] Enatescu V, Enatescu VR. [Doctor–patient dialogue, second edition]. Cluj-
Napoca: Dacia Publishing House; 2007 [published in Romanian].
[46] Tudose F. [Horizons of medical psychology]. Bucharest: Infomedica Publishing
House; 2003 [published in Romanian].
[47] National Commission. [Internal Medicine specialty curriculum]. BOE 033 de
07/02/2007 Sec 3. p. 5755–59 [published in Spanish].
[48] National Commission. [Cardiology specialty curriculum]. BOE 110 de 08/05/
2007 Sec 3. p. 19859–64 [published in Spanish].
[49] National Commission. [General Surgery specialty curriculum]. BOE 9409
ORDEN SCO/1260/2007 April [published in Spanish].
[50] National Commission. [Pediatric and its specific areas specialty curriculum.
BOE num 246. October 2006, p. 3565706 [published in Spanish].
[51] National Commission Family Medicine specialty curriculum. BOE 105 de 03/
05/2005 Sec 3. p. 15182–225 [published in Spanish].
[52] Baumal R, Benbassat J. Current trends in the educational approach for teaching
interviewing skills to medical students. Isr Med Assoc J 2008;10:552–5.
[53] Rosen J, Spatz E, Abramovitch H, Weinrib B, Wenger NS, Margolis CZ. A new
approach to teaching cross cultural skills to medical students. Med Teach
2004;26:126–32.
[54] Benbassat J, Baumal R, Borkan J, Ber R. Overcoming barriers to teaching the
behavioral and social sciences to medical students. Acad Med 2003;78:
372–80.
[55] Baranski J, Waszynski E, Steciwko A, editors. [The doctor–patient communi-
cation]. Wroclaw: Astrum Publishing Company; 2000 [published in Polish].
[56] Ratajska A, Kubica A. [What underlies the bad doctor–patient relationship
from psychological point of view?] Folia Cardiologica Excerpta 2010;5:84–7
[published in Polish].
[57] Stangierska I, Horst-Sikorska W. [General rules for communication between
patient and doctor]. Forum MedycynyRodzinnej 2007;1:58–68 [published in
Polish].
[58] Kern DE, Thomas PA, Hughes TA. Curriculum development for Medical Edu-
cation: a six-step approach. Baltimore, MD [u.a.]: Johns Hopkins University
Press; 1998.
C. Bachmann et al. / Patient Education and Counseling 93 (2013) 18–2626